Early treatment with bronchodilators and cortico … Primary care providers tasked with treating acute exacerbations of asthma and chronic obstructive pulmonary disease must be able to recognize exacerbation of symptoms and triage patients based on exacerbation severity to the appropriate level of … … About half of such patients are treated with antibiotics (primarily macrolides and quinolones) without a clear clinical indication. SABA-only treatment , although providing short-term relief of asthma symptoms, does not protect patients from severe exacerbations, and that regular or frequent use … Ann Allergy Asthma Immunol. Recognize asthma exacerbation early and provide appropriate education and treatment before symptoms worsen and require ED or inpatient care. The two case patients vary in severity. However, heliox could be beneficial for the management of patients with vocal cord dysfunction. Chapman KR, Verbeek PR, White JG, Rebuck AS. Effect of a short course of prednisone in the prevention of early relapse after … What is Isabelle.s respiratory severity today? In patients with type 2 asthma, dupilumab was associated with significantly lower annualized outpatient asthma exacerbation rates and lower total number of days using systemic corticosteroids, according to research presented at the CHEST Annual Meeting held … Despite published guidelines, the actual practice patterns are unknown. Quality asthma care involves not only initial diagnosis and treatment to achieve asthma control, but also long-term, regular follow-up care to maintain control. For chronic management of asthma, see Guidelines for Diagnosis and Management of Asthma. Most current corticosteroids treatment regimens for children admitted with asthma exacerbation consist of a 5-day course of prednisone or prednisolone. Reverse hypoxia with oxygen to maintain O2 sat>90%, Reverse airway obstruction rapidly with short-acting beta agonist (SABA) +/- systemic steroids for more severe exacerbations, Reduce short-term relapse with use of systemic steroids. Tapering the dose is not needed if patients are also given inhaled corticosteroids. 4-13 Therefore repeat assessment should be the primary factor in the decision to discharge the patient home, versus admit to the hospital. Check-in phone call encouraged in 1-2 days, Moderate symptoms (dyspnea at rest, interfering with usual activity, expiratory wheeze heard throughout, mild work of breathing, mild tachycardia; equivalent to RS 6-12 or PEF 50-79%1), Place pulse oximeter, provide oxygen prn to maintain SaO2 > 90%, Albuterol MDI 8 puffs (consider 4 puffs for children <4 years) (MDI strongly preferred, but if not available, give 5mg/3ml nebulized), Start Dexamethasone 0.6mg/kg, max of 16mg (onset within 2 hours, peak effect at 6 hours). This TOW is focused on introducing the UW General Pediatrics Outpatient Acute Asthma Treatment Guideline. NHLBI 2007 Asthma Guidelines — full report and summary reports available of these features of asthma determines the clinical manifestations, disease severity and response to treatment.2 Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing or chest tightness. The older patient has a moderate (verging on severe) respiratory status. KW - Exacerbation. However, it has a bitter taste that can make it very hard to administer to a young child. Case 2: A 12 year old girl with a history of asthma presenting with acute exacerbation. In 1993, the National Asthma Education and Prevention Program (NAEPP) pub-lished the Report of the Working Group on Asthma and Pregnancy(Asthma and Pregnancy Report 1993),5 which presented recommendations for the man-agement of asthma during pregnancy. Reverse hypoxia with oxygen to maintain O2 sat>90% ii. Asthma exacerbations are a major cause of disease morbidity, increases in health care costs, and, in some patients, a greater progressive loss of lung function. Endotracheal intubation and invasive mechanical ventilation may be needed for respiratory failure. Once airflow obstruction is relieved and PaCO2 and arterial pH normalize, patients can usually be quickly weaned from the ventilator. On exam, Michael.s BMI is at the 50th percentile and he is afebrile. Although ipratropium is not usually employed as a first-line bronchodilator to treat chronic asthma, it has been used extensively in hospital emergency departments as adjunctive therapy for the emergency treatment of acute asthma exacerbation. First-line treatment consists of inhaled bronchodilators (e.g., short-acting beta-2 agonists) for acute exacerbations and inhaled corticosteroids (e.g., budesonide) for long-term asthma control. Brooks M. FDA Oks New Maintenance Asthma Treatment Arnuity Ellipta. Such evidence will be used to highlight any unmet treatment needs and inform the current literature gap in this area. It may be mixed in same nebulizer as albuterol. ... Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care. Generally, volume-cycled ventilation in assist-control mode is used because it provides constant alveolar ventilation when airway resistance is high and changing. Pneumothorax occurs when air enters the pleural space and partially or completely causes the lung to collapse. She felt better after 2 puffs of albuterol but she needed more albuterol 2 hours later. Nebulized ipratropium can be co-administered with nebulized albuterol for patients who do not respond optimally to albuterol alone; some evidence favors simultaneous high-dose beta-2 agonist and ipratropium as first-line treatment. See patients: Every 2-6 weeks while gaining control Every 1-6 months to monitor control Every 3 months if step down in therapy is anticipated Patients who have presented due to inability to manage an acute asthma exacerbation at home Initial Treatment Inhaled SABA: up to 2 treatments 20 mins apart of 2-6 puffs MDI or Given its lower density, helium is thought to assist with delivery of bronchodilators to distal airways. In general, discharge is appropriate if forced expiratory volume (FEV1) or peak expiratory flow (PEF) … Curr Allergy Asthma Rep. 2003 Mar;3(2):179-89. This dosing is used for patients admitted to SCH. Therapy after a hospitalization or ED visit may last 5–10 days. In general, higher doses (prednisone 50 to 60 mg once a day) are recommended for the management of more severe exacerbations requiring in-patient care while lower doses (40 mg once a day) are reserved for outpatient treatment of milder exacerbations. (For further details, see Respiratory Failure and Mechanical Ventilation.). Theophylline has very little role in treatment of an acute asthma exacerbation. Introduction When reduced tidal volumes are necessary, a moderate degree of hypercapnia is acceptable, but if arterial pH falls below 7.10, a slow sodium bicarbonate infusion is indicated to maintain pH between 7.20 and 7.25. First-line treatment consists of inhaled bronchodilators (e.g., short-acting beta-2 agonists) for acute exacerbations and inhaled corticosteroids (e.g., budesonide) for long-term asthma control. Complementary diagnostic studies include peak expiratory flow rates , arterial blood gas, and, in some cases, chest x-ray. Patients having an asthma exacerbation are instructed to self-administer 2 to 4 puffs of inhaled albuterol or a similar short-acting beta-2 agonist up to 3 times spaced 20 minutes apart for an acute exacerbation and to measure peak expiratory flow (PEF) if possible. The ventilator should be set to a relatively low frequency with a relatively high inspiratory flow rate (>80 L/minute) to prolong exhalation time, minimizing auto positive end-expiratory pressure (auto-PEEP). For moderate exacerbation, use SABA + initiate oral steroids with dexamethasone (2 days; preferred) or prednisone (5 days). Families should receive coaching on how to administer medications through MDIs. Her brother and father also have asthma. As the severity of the presentation escalates, so do treatment regimens and the support required. Acute asthma exacerbations in children: Outpatient management He coughs a lot during the exam when he takes a deep breath. A wide variety of allergic and nonallergic triggers can incite an asthma exacerbation. A written asthma home management plan is essential to minimize the severity of exacerbations. Rank MA, Liesinger JT, Ziegenfuss JY, Branda ME, Lim KG, Yawn BP, et al. In patients with a peak expiratory flow of 50 to 79 percent of their personal best, up to two treatments of two to six inhalations of short-acting beta2 agonists 20 minutes apart followed by a reassessm… PERSPECTIVES The Pathophysiology of COVID-19 and SARS-CoV-2 Infection Treatment of COVID-19-exacerbated asthma: should systemic corticosteroids be used? Children should use a valved holding chamber with MDI.s (VHCs or .aerochamber.) Moderate: ESI Triage 3. Last full review/revision Jul 2019| Content last modified Jul 2019, © 2020 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA), © 2021 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, Drug Treatment of Asthma Exacerbations*, †, Musculoskeletal and Connective Tissue Disorders, www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf, Respiratory Failure and Mechanical Ventilation, Global Initiative for Asthma 2017 Report, Global Strategy for Asthma Management and Prevention, British Thoracic Society Asthma Guidelines. The inpatient asthma pathway is a detailed plan of the course of care for pediatric patients admitted for asthma treatment. Asthma is a chronic inflammatory disease that renders individuals prone to acute exacerbations. Patients who do not respond, have severe symptoms, or have a PEF persistently < 80% should follow a treatment management program outlined by the physician or should go to the emergency department (for specific dosing information, see table Drug Treatment of Asthma Exacerbations). Clinical Care Guidelines for Treatment of Asthma Exacerbations Children’s Hospital Colorado High Risk Asthma Program. Asthma control focuses on two domains: (1) reducing impairment—the frequency and intensity of symptoms and functional limitations currently or recently experienced by a The asthma pathway provides step-by-step guidance for evaluation and treatment of pediatric patients seen in the emergency department for asthma. Alternatively, 10–15 mg/hour continuous nebulization is similarly effective but increases frequency of adverse effects. These factors are combined in generating the respiratory scores used at Seattle Children.s Hospital (SCH), such as in their asthma pathway. Please also refer to the complementary UW General Pediatrics Outpatient Asthma Diagnosis Guidelines. The younger one has a history and exam consistent with a more mild respiratory status. Since then, there have been revisions to the general asthma treatment guidelines, His lungs have scattered high-pitched expiratory wheezes bilaterally. Table 1. In general, primary treatment (i.e., administration of oxygen, inhaled β 2-agonists, and systemic corticosteroids) is the same for all asthma exacerbations, but the dose and frequency of administration, along with the frequency of patient monitoring, differ depending on the severity of the exacerbation (Figure 1 and Table 3). Introduction Asthma exacerbations are a leading cause of paediatric hospitalisations. http://www.ghc.org/all-sites/guidelines/asthma.pdf, Cincinnati Children's Hospital Guidelines (used for SCH guidelines) What is your follow-up plan after today's visit? However, technical aspects of using helium for nebulization (availability, calibration of helium concentration, need for custom masks to avoid dilution with room air) have limited its widespread acceptance. Usual regimen is to continue frequent multiple daily doses until FEV1 or PEF = 50% of predicted or personal best and then lower the dose to twice a day, usually within 48 hours. What will be your follow-up plan after today.s visit? Corticosteroids are key in the treatment of asthma exacerbations. http://www.childrenshospital.org/az/Site2174/mainpageS2174P0.html, Copyright © 2021 Division of General Pediatrics, Department of Pediatrics,University of Washington. Kartik Kumar,1 Timothy S. C. Hinks,2 and Aran Singanayagam1 1National Heart and Lung Institute, Imperial College London, London, United Kingdom; and 2Respiratory Medicine Unit and National Institute for Health Research, Oxford … Anxiolytics and morphine are relatively contraindicated because they are associated with respiratory depression, and morphine may cause anaphylactoid reactions due to release of histamine by mast cells; these drugs may increase mortality, and the need for mechanical ventilation. Treating asthma exacerbations can be guided by a number of resources. Supplemental oxygen is indicated for hypoxemia and should be given by nasal cannula or face mask at a flow rate or concentration sufficient to maintain oxygen saturation > 90%. Outpatient treatment with oral prednisone offers a small advantage over placebo in treating patients who are discharged from the emergency department with an exacerbation of COPD. Asthma exacerbations can be classified as mild, moderate, severe, or life threatening. Terms | Contact Us | Webmaster, http://www.nhlbi.nih.gov/guidelines/current.htm, http://bestpractice.bmj.com/best-practice/monograph/1098/treatment/guidelines.html, http://www.seattlechildrens.org/healthcare-professionals/gateway/pathways/, http://www.ghc.org/all-sites/guidelines/asthma.pdf, http://www.cincinnatichildrens.org/assets/0/78/1067/2709/2777/2793/9199/6318985e-a921-4d93-95b7-33b6a827f9a5.pdf, http://www.uptodate.com/contents/acute-asthma-exacerbations-in-children-outpatient-management, http://www.childrenshospital.org/az/Site2174/mainpageS2174P0.html, NHLBI 2007 Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma, Seattle Children.s Hospital Asthma Pathway v.2.2, Group Health Asthma Diagnosis and Treatment Guideline, 2012, Mollie Grow, MD MPH [email protected], To provide criteria for diagnosing and treating acute asthma exacerbation and disposition based on clinical assessment. Discharge The response to initial treatment is a better predictor of the need for hospitalization than the severity of an exacerbation on presentation. Available at www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Introduction Systemic corticosteroids (prednisone, prednisolone, methylprednisolone) should be given for all but the mildest acute exacerbation; they are unnecessary for patients whose PEF normalizes after 1 or 2 bronchodilator doses. Different factors can trigger acute asthma exacerbations; it is important to learn how to reduce risks and when to seek medical assistance. It is a common chronic respiratory disease affecting 1–18% of population in different countries. videos -see below for Boston Children.s Hospital, Provider talking points (see 2007 NHLBI Summary Report Figure 7), Asthma assessment tools (such as the Childhood Asthma Control Test). Here we review the mechanisms that underpin acute asthma and its management (Table 1). This is covered in more detail in a separate TOW on asthma diagnosis. DETERMINE SEVERITY LEVEL OF ASTHMA EXACERBATION. Am J Med 1983; 75:259. Early treatment is the best strategy for management of asthma exacerbations. Dexamethasone Dosing Guide for Asthma … A mixture of helium and oxygen (heliox) is used to decrease the work of breathing and improve ventilation through a decrease in turbulent flow attributable to helium, a gas less dense than oxygen. Ipratropium bromide is a quaternary anticholinergic bronchodilator that is commonly used to treat obstructive lung disease. See the attached UW General Pediatrics outpatient clinic guidelines for recommended treatment approaches you would use to decide on Michael.s mild asthma, Isabelle.s moderate asthma, and to treat more severe cases you might encounter in clinic. Goals for Asthma Care Quality asthma care involves not only initial diagnosis and treatment to achieve asthma control, but also long-term regular follow-up care to maintain control. The last was 2 years ago. The legacy of this great resource continues as the Merck Manual in the US and Canada and the MSD Manual outside of North America. Recognize asthma exacerbation early and provide appropriate education and treatment before symptoms worsen and require ED or inpatient care. KW - Asthma. Frequency and severity may fluctuate over time for patients in any severity category. Pharmacologic management includes the use of control agents such as inhaled corticosteroids, long-acting bronchodilators (beta-agonists and anticholinergics), theophylline, leukotriene modifiers, and more recent strategies such as the use of anti-immunoglobulin E (IgE) antibodies (omalizumab) and anti-IL-5 antibodies in selected patients. Asthma exacerbations are important events that affect disease control, but predictive factors for severe or moderate exacerbations are not known. Dosage of Medications for Asthma Exacerbations. We do not control or have responsibility for the content of any third-party site. No one smokes at home, but she sometimes babysits for neighbors who smoke. (what guidelines can you consult? !Indication:*MODERATEASEVERE*exacerbation* Here we review the mechanisms that underpin acute asthma and its management . Use in adults is controversial and may be contraindicated if significant cardiovascular disease is present. In the case of the younger child, this could be termed wheezing or reactive airway disease that may warrant an asthma diagnosis in the future if he has more wheezing episodes that are responsive to albuterol. A written asthma home management plan is essential to minimize the severity of exacerbations. Mechanical ventilation should be strongly considered if there is no convincing improvement after 1 hour of NIPPV. Ipratropium should be added to beta-2 agonists and not used as first-line therapy. http://www.cincinnatichildrens.org/assets/0/78/1067/2709/2777/2793/9199/6318985e-a921-4d93-95b7-33b6a827f9a5.pdf, UpToDate Table 3. Patients should also have a check-up scheduled to assess their asthma control within 1-3 months after an exacerbation. Mechanical ventilation should be used rather than NIPPV if patients have any of the following: Facial abnormalities (ie, surgical, traumatic) that could impede noninvasive ventilation. 7,10,11 For patients who were already 491 on ICS, step-up therapy should be considered after … Asthma is a chronic inflammatory disease that renders individuals prone to acute exacerbations. IV methylprednisolone can be given if an IV line is already in place and can be switched to oral dosing whenever necessary or convenient. METHODS Twenty eight children aged 6–14 years with asthma of mild to moderate severity were studied for six months. PRED has been the oral steroid used in the treatment of pediatric asthma exacerbations for decades. Of these causes, which of the following is most common in patients with secondary spontaneous pneumothorax? Asthma exacerbations can be classified as mild, moderate, severe, or life threatening. An extensively revised, retracted, and replaced article by Stefan et al 1 in this issue of JAMA Internal Medicine assesses outcomes associated with antibiotic treatment in adults hospitalized for asthma exacerbations. In these patients, peak airway pressure does not reflect the degree of lung distention caused by alveolar pressure. If moderate at 1 hour, may repeat albuterol MDI 8 puffs and observe an additional hour, Severe symptoms (dyspnea at rest, interfering with talking, loud inspiratory and expiratory wheezes, moderate to severe work of breathing, moderate tachycardia; equivalent to SCH RS 6-12 or PEF <501,), 8 puffs or albuterol continuous nebulized 5mg/hour with ipratropium 0.75mg, Start Dexamethasone 0.6mg/kg, max of 16mg (onset within 2 hours, peak effect at 6 hours)(see note above about prednisone dosing), Repeat assessments at minimum of 30 minutes, 1 hour to determine response to treatment and disposition, If safe for discharge from clinic to home, Provide second dose of dexamethasone 0.6mg/kg at 24 hours, Continue albuterol MDI 2-4 puffs at home every 4 hours for 24 hours and then prn, Moderate not responding to initial albuterol and steroid within 2 hours, Moderate symptoms clinic follow-up within 2 weeks, then within 1-3 months, Mild symptoms responding to lower-dose albuterol, return within 1-3 months, All patients to have an asthma action plan when leave clinic, As above, must consider acute infection including pneumonia, croup, and/or bronchiolitis, and aspiration (especially in young children), No indication for ipratropium in mild to moderate asthma exacerbation, only for severe disease, Inhaled steroid initiation not equivalent to oral steroids in onset of action, Lack of evidence for peak flow zones to guide disposition, If steroids given within 1 hour of presentation for acute care, more likely to prevent admission to the hospital, Dexamethasone for 2 days has been shown to be as effective as prednisone for 5 days in several studies for outpatient asthma medication dosing; this is the recommended strategy at SCH, Do not allow patients to take albuterol more often than every 4 hours for more than 24 hours at home without assessment, Patients should call their provider and be assessed in person if they start oral steroids at home, Over 12 months, 2+ admits or 3+ ED visits, Cannot sense airflow obstruction or its severity, Risk for medication non-adherence: depression, high stress, socioeconomic risks, attitudes/beliefs against medication benefit, Does Michael have asthma? http://www.seattlechildrens.org/healthcare-professionals/gateway/pathways/, Group Health asthma guidelines based on 2007 NHLBI Inhaled bronchodilators (beta-2 agonists and anticholinergics) are the mainstay of asthma treatment in the emergency department. The diagnosis is usually clinical and should involve early evaluation of the severity of asthma exacerbation. http://www.uptodate.com/contents/acute-asthma-exacerbations-in-children-outpatient-management, Boston Children.s Hospital Outpatient clinic how-to videos Treatment includes, Inhaled bronchodilators (beta-2 agonists and anticholinergics), (See also Asthma and Drug Treatment of Asthma.). Asthma exacerbations requiring oral systemic corticosteroids ‡ 0–1/year ≥ 2 exacerb. Her RR is 30 and HR is 102. Nebulized treatment is preferred for younger children because of difficulties coordinating MDIs and spacers. Furthermore, the usual guidelines for prompt initiation of systemic glucocorticoids for asthma exacerbations should be followed, as delaying therapy can increase the … As the severity of the presentation escalates, so do treatment regimens and the support required. August 28, 2007. 1 All rights reserved. 1 The 2007 Expert Panel Report-3 Guidelines for the Diagnosis and Management of Asthma 1 suggest a stepwise approach for managing asthma based on symptom severity. Terbutaline may be preferable to epinephrine because of its lesser cardiovascular effects and longer duration of action, but it is no longer produced in large quantities and is expensive. Diagnosis Asthma exacerbations are acute or subacute episodes of progressively worsening shortness of 20 mcg ipratroprium and 100 mcg albuterol/puff, 1 puff every 30 minutes for 3 doses, then every 2–4 hours as needed. Corticosteroids are key in the treatment of asthma exacerbations. However, these medications are associated with poor taste and … Her lung exam is notable for diffuse expiratory wheezes, mild intercostal retractions, and a prolonged expiratory phase. 1.Global Initiative for Asthma 2017 Report, Global Strategy for Asthma Management and Prevention, 2. 1 The 2007 Expert Panel Report-3 Guidelines for the Diagnosis and Management of Asthma 1 suggest a stepwise approach for managing asthma based on symptom severity. Relief me… ), What is Michael.s respiratory severity today? Alternative steroid dosing for moderate to severe asthma is prednisone or prednisolone (2 mg/kg/day) for a total course of 5-10 days, depending on severity of exacerbation and history of severity. Patients should be taught the correct usage of inhalers for self-medication and measurement of peak expiratory flow (PEF) to self-monitor disease progression and severity. Criteria for exacerbation severity are based on symptoms and physical examination parameters, as well as lung function and oxygen saturation. Using a cohort of asthma patients, we will examine the treatment pathways for asthma patients to their severe asthma diagnosis and describe health care resource utilisation including referrals through to severe asthma. An asthma exacerbation is the acute worsening of asthma symptoms caused by reversible lower airway obstruction. OBJECTIVE To investigate the efficacy of an increased dose of inhaled steroid used within the context of an asthma self management plan for treating exacerbations of asthma. Please see the accompanying guidelines that consist of a flow diagram (algorithm) and accompanying text. The goals of managing an asthma exacerbation are prompt recognition, rapid reversal of airflow obstruction, avoidance of relapses, and prevention of future episodes. A wide variety of allergic and nonallergic triggers can incite an asthma exacerbation. Higher doses provide no advantage in severe exacerbations. 0.01 mL/kg /dose subcutaneously (maximum 0.4–0.5 mL every 20 minutes for 3 doses or every 4 hours as needed), 0.2–0.5 mg subcutaneously every 20 minutes (for maximum of 3 doses) or every 2 hours as needed. The goals of managing an asthma exacerbation are prompt recognition, rapid reversal of airflow obstruction, prevention of relapses, and forestalling future episodes. British Thoracic Society Asthma Guidelines. The treatment of asthma exacerbation currently begins with asthma self-management in the outpatient setting. Mild: ESI Triage 4. As a chronic disease with intermittent exacerbations, asthma is treated primarily in the outpatient setting by primary care physicians. boy with a history of eczema, comes in for an acute visit in February. Privacy | The use of a short course of oral corticosteroids (OCS), or "steroid burst," is standard practice in the outpatient management of acute severe exacerbations of asthma. The goals of managing an asthma exacerbation are prompt recognition, rapid reversal of airflow obstruction, avoidance of relapses, and prevention of future episodes. Nebulized solution: 0.63 and 1.25 mg/3 mL, 0.075 mg/kg (minimum 1.25 mg) every 20 minutes for 3 doses, then 0.075–0.15 mg/kg up to 5 mg every 1–4 hours as needed, Alternatively, 0.25 mg/kg/hour continuous nebulization, 1.25–2 mg every 20 minutes for 3 doses, then 1.25–5 mg every 1–4 hours as needed, Alternatively, 5–7.5 mg/hours continuous nebulization, Nebulized solution: 500 mcg/2.5 mL (0.02%), 0.25–0.5 mg every 20 minutes for 3 doses, then every 2–4 hours as needed, 0.5 mg every 20 minutes for 3 doses, then every 2–4 hours as needed. Highlights of this particular pathway: NA, Follow-up criteria/recommendations: f/u call within 1-2 days; f/u in-person within 2 weeks for moderate-severe, all patients should leave clinic with an asthma action plan and have clinic follow-up within 1-3 months, Ages 1-4, 5-11, 12+ to be evaluated with age-appropriate vital sign cut-points, Dyspnea (tachypnea in young children) in patient with known or suspected asthma, Other acute primary respiratory diagnosis including pneumonia, croup, and/or bronchiolitis, Children with other chronic disease such as CF, congenital heart or pulmonary disease, immune disorders (consult specialists), Unilateral wheeze, suggestive of foreign body aspiration, Mild symptoms (dyspnea with activity only, end-expiratory wheeze, no or mild work of breathing (only intercostal/subcostal retractions), no tachycardia; equivalent to SCH Respiratory Score (RS) 1-5, or Peak Expiratory Flow (PEF) >80% ), Albuterol MDI 4 puffs, observe response at 30 minutes (MDI strongly preferred, but if not available, give 2.5mg/3ml nebulized), Consider oral steroid based on patient history of asthma severity (see high risk patient criteria below) and control, and likelihood to progress to more severe symptoms, If worsen or not improving, go to moderate pathway and give additional 4 puffs albuterol and then steroids, D/c to home with albuterol 2-4 puffs prn and follow-up prn. Subcutaneous administration is no more effective than inhalation and may have more adverse effects. The impact of asthma medication guidelines on asthma controller use and on asthma exacerbation rates comparing 1997-1998 and 2004-2005. Managing outpatient asthma exacerbations. For severe exacerbation, initiate SABA + ipratropium, oral steroids, and follow response, refer to ED care if not responding adequately after 1 hour.
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